The length of the small intestine in a he althy person is about 6 meters. The total surface area of the small intestine mucosa is huge - about 500 m2, which is commensurate with the area of a tennis court; colon - 4 m2 - equal to the area of a table tennis table. When a large part of the intestine is removed, its function is significantly reduced, which leads to intestinal failure and the appearance of short bowel syndrome. Recovery is especially difficult if less than 2 meters of intestine is preserved.
Main reasons for major bowel resection:
- thrombosis and embolism of intestinal vessels (30-90%);
- Crohn's disease (50%);
- Gardner syndrome (20%);
- periarteritis nodosa (15%);
- intestinal tumors (1-16%);
- postradiation enteritis (10%);
- Intestinal angiomatosis (4%).
Intestinal Anatomy
Food from the stomach enterssmall intestine, consisting of three sections, which differ in their functions. Next, a lump of digested food - chyme - enters the large intestine, which also consists of three sections. Between them is the ileocecal valve, which acts as a damper. The lower part of the large intestine - the rectum - serves for the accumulation of feces, ends with the anus.
Operation options
Depending on the localization of the pathology due to which the operation is performed, part or all of the small intestine, part of the colon or rectum can be removed. There are three types of resection.
- Removal of part of the small intestine, while preserving part of the ileum, ileocecal valve and large intestine. These patients rarely experience serious postoperative complications.
- Removal of part of the jejunum, the entire ileum and the ileocecal valve with the creation of a connection (anastomosis). Such patients will have steatorrhea, nutritional deficiencies, and other disorders. However, over time, it is possible for the body to adapt to new conditions.
- Resection of the large intestine (colectomy) with the creation of an artificial fistula from the jejunum (jejunostomy) or ileum (ileostomy) through the abdominal wall to the outside. Through the created hole, feces will be removed, so it is called the unnatural anus. In these patients, bowel adaptation is not observed. Possible constant intake of saline, glucose, antidiarrheal drugs, in some patients - parenteralfood.
Features of postoperative disorders depending on the place of resection
Depending on which part of the organ was removed, certain symptoms predominate.
Digestion of all kinds of nutritional compounds occurs in the small intestine, and the vast majority of hydrolyzed substances, vitamins, microelements and water are absorbed here. Resection of the small intestine results in:
- deficiency of all kinds of nutrients in the body when they enter the digestive tract normally;
- diarrhea due to a sharp decrease in water absorption.
Each part of the small intestine does its job, so the resection of different parts of the intestine is manifested by different symptoms.
Water and nutrients are absorbed primarily in the upper intestine (jejunum). The secrets produced in the digestive tract, bile, enzymes, are absorbed mainly in the lower section (ileum), part of the water is also absorbed here. Therefore:
- Resection of the jejunum does not cause diarrhea as the remaining ileum takes over the absorption of the fluid.
- Removal of the ileum causes severe diarrhea, as the secrets produced in the previous sections of the tract have nowhere to be absorbed, they dilute the chyme, thereby causing frequent watery stools. In addition, the absence of the ileum prevents the absorption of bile and fatty acids, which pass into the large intestine, where they attract water, aggravating diarrhea.
Ileocecal valve that closes the passage between the thin andlarge intestine, is of great importance in digestion. Removal of this flap for extensive small bowel resection:
- accelerates the passage of chyme, resulting in reduced absorption of electrolytes, nutrients and fluids;
- promotes the penetration of microflora from the large intestine into the small intestine, which leads to an overgrowth of bacteria.
The large intestine absorbs some of the water and electrolytes, forming feces. The microflora of this part of the body synthesizes vitamins of group B and vitamin K. Here the final fermentation of fats to short fatty acids takes place, which are important energy substrates and also have an antimicrobial effect.
Resection of the large intestine leads to the loss of water and minerals, to a lack of vitamins. Fecal masses do not have time to form. The preservation of the colon greatly compensates for malabsorption of carbohydrates and fats, as well as fluids.
The totality of all disorders resulting from intestinal resection is united under the general name - short bowel syndrome. All disorders that arise are due to:
- digestion disorder;
- malabsorption;
- trophological deficiency;
- involvement of other organs in the pathological process.
Recovery after bowel removal
Changes in the body after bowel resection surgery occur in three stages.
- Post-operative stage –lasts from a week to several months. It is characterized by water diarrhea (up to 6 liters per day), accompanied by a loss of sodium, potassium, chlorides, magnesium, bicarbonates. This causes dehydration and severe electrolyte deficiency, the development of severe metabolic disorders, a violation of protein, water, electrolyte and vitamin metabolism.
- Subcompensation phase - continues for a year after bowel resection. There is a gradual adaptation of the digestive system: the frequency of stool decreases, metabolic processes normalize. In this case, the absorption of nutrients is not restored. Therefore, vitamin deficiency and anemia are noted, manifested by general weakness, dermatitis, sensitivity disorders (numbness, goosebumps, tingling), dry skin, brittle nails. Almost all patients are underweight.
- Adaptation phase - begins approximately two years after bowel resection. For its beginning, a compensatory structural reorganization of the small intestine is necessary. If the intestine adapts, the patient's condition stabilizes. Symptoms of diarrhea will decrease, body weight will be restored. But complications may arise in the form of the synthesis of stones in the gallbladder and bladder, the appearance of stomach ulcers. Anemia may persist.
After bowel resection, restoration of functions is possible if provided as early as possible:
- normalization of the content of proteins, fats, carbohydrates, vitamins in the body;
- start digestion stimulation;
- start processessuction;
- restoration of the intestinal microbiota.
The most effective way to start adaptation processes in the intestines is to make it work. Without the supply of nutrients, the body will not begin to recover. Therefore, it is important to start enteral nutrition as early as possible. The contact of nutrients with enterocytes triggers the synthesis of hormones and enzymes of the intestine and pancreas, which stimulates adaptation processes. The nature of nutrition also plays a big role. The diet should contain dietary fiber, glutamine, short fatty acids.
Principles of nutrition in the postoperative period
In the postoperative period of bowel resection to save the patient's life, measures to prevent complications are paramount: dehydration, hypovolemia, hypotension, electrolyte disturbances. When these conditions are eliminated, on the 2-3rd day after the operation, parenteral (bypassing the digestive tract) nutrition begins to be established with the introduction of energy substrates. Large volumes of glucose, isotonic solutions of sodium chloride, calcium, potassium, magnesium s alts are administered intravenously.
When the patient's condition is stabilized, diarrhea is under control, enteral (using the digestive tract) nutrition is prescribed. After a small resection of the intestine, nutrition is prescribed for 3-5 days, after an extensive one - through a probe after 2-4 weeks. May increase diarrhea after the start of enteral nutrition. However, it cannot be stopped, it is necessary to reduce the rate of drug administration.
Gradually, as the patient's condition improves, they switch to normaloral (through the mouth) food. Usually, diets No. 0a, 1a, 1, 1b are prescribed sequentially.
Diet 0a has a low energy value, so the patient is deficient in nutrients. Protein deficiency is especially dangerous. The processes of catabolism begin to prevail over the processes of synthesis, recovery mechanisms are inhibited, which is fraught with an unfavorable outcome, especially if the metabolic processes have already been disturbed before the operation. Therefore, combined nutrition with parenteral and enteral administration of nutrients is prescribed. The total calorie content is significantly increased and amounts to 3500 kcal per day.
In case of good tolerance of the zero diet, after 2-3 days the patient is prescribed diet No. 1a (another name is 0b). As a rule, the patient remains on this diet option after bowel resection until discharge from the medical facility.
Post-Discharge Nutrition Principles
Establishing the right diet and following it strictly are the most important conditions for recovery.
Two weeks after the bowel resection, the diet is changed from No. 1a to 1 surgical. But within 3-4 weeks it is recommended to wipe all food. The principle of thermal and mechanical sparing must be observed. Dishes are steamed or boiled, all food is thoroughly crushed to a liquid or mushy consistency, fruits are rubbed, jelly and compotes are prepared from them. Exclude products that increase rotting and fermentation - canned food, smoked meats, spices.
If this diet is well tolerated,you can gradually switch to the non-mashed version of diet No. 1 surgical. This means a daily reduction in meals with maximum mechanical and thermal processing. The good tolerance of the new dish indicates the formation of compensatory reactions of the digestive tract, the normalization of its functions, which allows you to expand the diet. Such a transition should take at least 2 weeks, and sometimes reach up to 5-6.
In the non-mashed version of the diet, food can be boiled, after boiling it can be baked in a piece. A wider choice of vegetable and fruit purees, compotes is allowed. Meals should be fractional - at least 6 times a day.
The consequences of bowel resection include increased sensitivity of the digestive tract to certain foods. First of all, we are talking about whole milk, as well as fatty foods, including vegetable oil, strong broths, decoctions, fresh vegetables and fruits, acidic foods. Milk intolerance is noted in 65% of patients after bowel resection, in this case, nutrition should be changed, there is no need to practice “training” a fragile organ with dairy products. Whole milk should be replaced with soy or other plant-based milk for several months or even years until lactose intolerance passes.
Diets in the first month after surgery
In the first month after resection, both the small and large intestines are prescribed the same nutrition.
Diet 0a.
Appointed for two or three days. Food is liquid or jelly-like. The calorie content of the diet is 750-800 kcal. You can drink about 2 liters of free liquid.
Allowed: weak meat broth without fat, rice broth with butter, strained compote, liquid jelly, rosehip broth with sugar, no more than 50 ml of freshly made juice from fruits or berries, diluted 2 times with water. On the third or fourth day, when the condition stabilizes, you can add a soft-boiled egg, butter or cream.
Excluded: solid foods, whole milk and cream, sour cream, vegetable juices, carbonated drinks.
Diet 1a surgical.
Calorie content 1500-1600 kcal, liquid - up to 2 liters, meals - 6. Pureed liquid cereals from oatmeal, rice, buckwheat cooked in meat broth or water in half with milk are added to already introduced dishes; mucous soups from cereals in vegetable broth; steamed protein omelet, steamed purees or soufflés from meat or fish (without fascia and fat), cream (up to 100 ml), jelly, mousses from non-acidic berries.
Diet 1b surgical.
This is a more advanced version of the previous diet and serves to prepare the patient's digestive tract for the transition to good nutrition. The calorie content of the diet increases to 2300, meals remain 6. Dishes should not be hot (no more than 50 ° C) and not cold (at least 20 ° C).
Soups are added in the form of mashed potatoes or cream, steamed dishes from mashed boiled meat, fish or chicken; fresh cottage cheese, mashed with cream to the consistency of thick sour cream, steamed dishes from cottage cheese, fermented milk products, baked apples, mashed vegetables and fruits, white crackers. Porridge is cooked onmilk, milk can also be added to tea.
Diet after small bowel resection
When resection of the intestine, the following list of dishes and products is recommended:
- Yesterday's wheat bread.
- Soups in a weak broth - meat or fish, with meatballs, vermicelli or boiled cereals.
- Cutlets or meatballs from beef, veal, rabbit, chicken, turkey. Lean fish, steamed or boiled.
- Potatoes and carrots as a separate dish or side dish - boiled and mashed. Exclude cabbage, beets, radishes, turnips, tomatoes, garlic, sorrel, mushrooms.
- Porridges (except barley and millet) on water with the addition of a third of milk, dishes from legumes, pasta.
- Boiled egg or steam omelet from two proteins.
- Allowed in a small amount of milk (only in the composition of cereals), sour cream and cream (as an additive to dishes). Fresh cottage cheese, baked or steamed cottage cheese puddings are allowed. When milk intolerance appears, you will have to stop using milk for a long time (sometimes forever). Dairy products are being replaced with soy products, which are also a rich source of protein.
- Kissels, pureed compotes, jelly, baked apples only.
- Rosehip broth, tea, black coffee.
To support patients with extensive bowel resection in the postoperative period, nutrient mixtures are often used, which are used as a supplement to the diet or the main food. Similar mixtures developed abroad and in our country are widely represented in pharmacies and stores. They allowsignificantly increase the calorie content of the diet, provide plastic and energy needs, while not overloading the enzyme systems of the digestive tract.
Diet after colon resection
Special nutrition should be in patients after resection of the large intestine and removal of the unnatural anus. Such patients should observe three main nutritional parameters:
- amount eaten;
- quality of products that either thin or thicken feces;
- meal time.
The amount of solid food eaten should always be in the same proportion with the liquid drunk. For example, for breakfast, the patient always eats one bowl of porridge and drinks one glass of tea. Porridge can be from different cereals, and tea can be of different degrees of tea leaves. Lunch, dinner, and other meals should also include a stable amount of solid food and fluids. So it will be possible to control the density of the stool.
If it is necessary to thicken the feces, porridge is cooked thicker, from rice and buckwheat, semolina and peas are excluded. Cancel everything that promotes peristalsis and gas formation: sour dairy products, fresh fruits, coffee with milk, plum compote.
To thin the feces, increase the proportion of liquid in the diet, reduce the portion of food, reduce the amount of s alt, introduce prunes, fruits, yogurt, vegetable soups without meat into the diet.
The third condition for a normal stool is eating at certain, established times andforever watch.
Patient rehabilitation
After bowel resection, rehabilitation includes physiotherapy and kinesitherapy - exercise therapy.
After surgery, patients experience disorders associated with the disease itself, surgery, anesthesia, lack of movement. For example, pain at the incision site leads to a decrease in inhalation volume, the patient may not use the diaphragm at all. In addition, stagnation and anesthesia cause spasms of the small bronchi, blocking them with mucus. Therefore, after the operation, especially if the patient is on bed rest for a long time, breathing exercises are necessary that involve the entire volume of the lungs, allowing the lungs to expand.
In the postoperative period, exercise allows you to:
- prevent complications - congestive pneumonia, atelectasis, intestinal atony, thrombosis;
- improve the activity of the cardiovascular and respiratory systems;
- improve psycho-emotional state,
- prevent adhesions,
- to form an elastic, mobile scar.
Contraindications to exercise therapy: serious condition, acute cardiovascular failure, peritonitis.
If there are no contraindications, exercises begin from the first hours after the operation - breathing exercises, warm-up for fingers, feet and hands, chest massage.
Bed rest must be observed for 1-6 days after surgery, depending on the patient's condition. Appointbreathing exercises, light exercises for the abdominal muscles, tasks for diaphragmatic breathing, contraction of the muscles of the perineum (reduction of congestion in the pelvic organs), torso rotations.
On the 6th-12th day, you can practice lying down, sitting and standing.
On the 12th-14th day, the choice of types of physical activity expands significantly, you can use gymnastic equipment, sedentary games, dosed walking is allowed.
A month after the operation, it is necessary to perform general tonic exercises, tasks to strengthen the abdominal muscles to prevent postoperative hernias. Walking, elements of sports games, nearby hiking, skiing are recommended.
